Acetaminophen and Codeine: Uses, Dosing, and Side Effects
Last updated September 6, 2026.
**Acetaminophen and codeine is a prescription combination pain reliever that pairs a non-opioid analgesic with codeine, an opioid.** Acetaminophen lowers pain signaling and fever through the central nervous system, and codeine is converted by your body into morphine, which binds opioid receptors in the brain and spinal cord to blunt the pain you feel. The single most important safety point is that both halves carry a ceiling: opioids can slow your breathing, especially with alcohol or sedatives, and acetaminophen can damage the liver above 4,000 mg in 24 hours from all sources combined.
What does it treat?
Doctors prescribe acetaminophen and codeine for short courses of mild to moderate pain that has not responded to acetaminophen or ibuprofen alone. Typical situations include dental work such as an extraction, a fracture or bad sprain in the first days, pain after a minor surgery or procedure, kidney stone pain, and some acute back or musculoskeletal injuries. It is sold as generic acetaminophen and codeine phosphate tablets and under the brand Tylenol with Codeine No. 3 (300 mg acetaminophen with 30 mg codeine) and No. 4 (300 mg acetaminophen with 60 mg codeine), plus an oral solution containing 120 mg acetaminophen and 12 mg codeine per 5 mL. Codeine also appears in cough products, but those are different formulations and are not interchangeable with these pain tablets. It is not intended for long-term or around-the-clock pain control, and it is not approved for anyone under 12 years old.
How do you take it?
The usual adult dose of the 300 mg / 30 mg tablet is 1 or 2 tablets every 4 hours as needed for pain, with a maximum of 12 tablets in 24 hours; for the 300 mg / 60 mg tablet the usual dose is 1 tablet every 4 hours, up to 6 tablets in 24 hours. The hard ceilings are 4,000 mg of acetaminophen and 360 mg of codeine in 24 hours, and the acetaminophen total has to include every other product you take, since cold and flu combinations, sleep aids, and many other prescription pain pills contain it too. Take it with food or milk if it upsets your stomach, and measure the liquid with the dosing syringe or cup that comes with it rather than a kitchen spoon. Because this is dosed as needed, there is no missed dose to make up: take the next dose when pain returns and the interval has passed, and never double up or shorten the gap between doses. Use the lowest dose that works for the fewest days, and call your doctor if pain is not controlled at the prescribed dose, if you need it beyond the few days planned, if you feel very sedated, or if you become constipated in a way that does not respond to fluids, fiber, and a stool softener.
Side effects to know
- Common: Drowsiness, dizziness or lightheadedness when standing, nausea, vomiting, constipation, dry mouth, itching, and sweating are the usual effects, and they tend to be strongest with the first doses and after any dose increase.
- Serious: Stop the medicine and get help right away for slow, shallow, or pauses in breathing, extreme sleepiness or being hard to wake, blue or gray lips or fingertips, confusion, fainting, or a seizure. Also stop and call a doctor for signs of liver injury such as upper right abdominal pain, dark urine, pale stools, or yellowing of the eyes or skin, and for a rash with blistering or peeling skin, which can signal a rare but serious acetaminophen reaction.
Who should not take it?
Do not take this drug if you have significant breathing problems, severe asthma flaring without monitoring, a known or suspected bowel obstruction including paralytic ileus, or an allergy to acetaminophen or codeine. It is not for children under 12, and not for anyone under 18 after tonsil or adenoid surgery, because some people convert codeine to morphine very fast and have died from it; adults who are ultra-rapid metabolizers face the same risk. Talk to your doctor first if you have liver disease or hepatitis, kidney disease, sleep apnea, COPD, a head injury or seizures, adrenal insufficiency, low thyroid, an enlarged prostate or urinary retention, gallbladder or pancreas problems, or a personal or family history of substance use disorder. Combining it with benzodiazepines, muscle relaxants, sleep medicines, gabapentin or pregabalin, other opioids, or antihistamines raises the risk of dangerous sedation and slowed breathing; certain antidepressants, antifungals, and HIV or hepatitis C drugs change codeine and acetaminophen levels, and MAO inhibitors within the last 14 days are off limits. Serotonin syndrome is possible with SSRIs, SNRIs, triptans, and linezolid. Do not drink alcohol at all while taking it, including beer, wine, and alcohol-containing cough or cold syrups, since alcohol adds both liver strain and breathing suppression. In pregnancy, use only if your doctor decides the benefit is worth it, since prolonged use late in pregnancy can cause opioid withdrawal in the newborn, and current FDA labeling says codeine is not recommended while breastfeeding because of reports of serious harm and death in breastfed infants. Ask your prescriber about having naloxone at home, especially if anyone in the household uses other sedating medicines.
When is it an emergency?
Call 911 in the US for breathing that is slow, shallow, or stops, for lips or skin turning blue or gray, for someone who cannot be woken, or for a seizure, and give naloxone right away if you have it. Call 911 also for swelling of the face, lips, tongue, or throat, hives with trouble breathing, or a rash with blistering or peeling skin, which point to a severe allergic reaction. For any suspected overdose or extra dose, including a child who got into the bottle, call Poison Control at 1-800-222-1222 immediately even if the person looks completely fine, because acetaminophen liver injury can be silent for a day or two and the antidote works best when it is started early. Bring the bottle or a photo of the label so the team knows how much acetaminophen and codeine is involved.
What a Pymander AI doctor consult looks like
Illustrative example, not a real member's messages.
Common questions
What is the maximum I can take in a day?
With the 300 mg / 30 mg tablet, the label allows 1 or 2 tablets every 4 hours as needed, up to 12 tablets in 24 hours. With the 300 mg / 60 mg tablet, it is 1 tablet every 4 hours, up to 6 tablets in 24 hours. The absolute limits are 4,000 mg of acetaminophen and 360 mg of codeine per day. Many doctors set a lower personal ceiling, often 3,000 mg of acetaminophen, if you drink alcohol, are older, are underweight, or have any liver history. Take the lowest dose that controls your pain and stop as soon as you can.
Can I drink alcohol while taking it?
No. Alcohol and acetaminophen together raise the risk of liver injury, and alcohol and codeine together suppress breathing in a way that can be fatal even at doses each would tolerate alone. That includes beer, wine, spirits, and alcohol-containing cough and cold syrups. If you drink three or more alcoholic drinks a day on a regular basis, tell your prescriber before you start, because that changes both the drug choice and the safe acetaminophen ceiling. Wait until you are fully off the medication before drinking again.
Is it safe during pregnancy or breastfeeding?
Codeine is not recommended while breastfeeding. Some people convert codeine to morphine unusually fast, morphine passes into breast milk, and FDA labeling cites reports of severe sedation and death in breastfed infants. In pregnancy, it is used only when your doctor judges the benefit worth the risk, and prolonged use in the later part of pregnancy can cause neonatal opioid withdrawal syndrome, which needs specialist care at delivery. Acetaminophen alone is generally the preferred pain option in pregnancy at the lowest effective dose. Tell your obstetric team before you fill this prescription.
Do I need to take it with food?
Food is not required for the medicine to work, but taking it with food or milk helps if it makes you nauseated, which is common in the first days. Drink plenty of water and add fiber or a stool softener from the start, since constipation from codeine is expected rather than unusual. Avoid grapefruit juice in large amounts, because it can change how your body handles the drug. Measure liquid formulations with the supplied syringe or cup, not a kitchen spoon.
What are the signs of an overdose?
Opioid overdose looks like slow or shallow breathing, pinpoint pupils, extreme sleepiness or being unable to wake the person, limp body, and blue or gray lips, face, or fingertips. Acetaminophen overdose is different and sneakier: the first day may bring only nausea, vomiting, sweating, and poor appetite, with liver damage showing up a day or two later as upper right abdominal pain, dark urine, and yellowing of the eyes. Call 911 for anyone who is unresponsive or struggling to breathe and give naloxone if you have it. Call Poison Control at 1-800-222-1222 for any suspected extra or excess dose, even if the person feels fine, because the acetaminophen antidote works best early.
What medicines interact with it?
The highest risk combinations are other sedatives: benzodiazepines such as alprazolam or lorazepam, muscle relaxants, sleep medicines, gabapentin, pregabalin, other opioids, and sedating antihistamines, all of which add to slowed breathing. Do not use it within 14 days of an MAO inhibitor. SSRIs, SNRIs, triptans, and linezolid raise the risk of serotonin syndrome. Certain antifungals, antibiotics, seizure medicines, and HIV or hepatitis C drugs change codeine and acetaminophen levels in either direction. The most frequent real world problem is stacking acetaminophen without realizing it, so read the active ingredients on every over the counter and prescription product you take and give your pharmacist a full list.